Healthcare Provider Details

I. General information

NPI: 1225695414
Provider Name (Legal Business Name): ELIZABETH ETHRIDGE BEASLEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 08/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ERWIN RD
DURHAM NC
27705-4699
US

IV. Provider business mailing address

511 S MANGUM ST APT 1044
DURHAM NC
27701-1002
US

V. Phone/Fax

Practice location:
  • Phone: 919-668-0289
  • Fax:
Mailing address:
  • Phone: 404-345-5118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number126125
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: